Provider Demographics
NPI:1790809283
Name:MEDICIS, GERARD W (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:W
Last Name:MEDICIS
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0033
Mailing Address - Country:US
Mailing Address - Phone:812-402-8333
Mailing Address - Fax:812-402-8331
Practice Address - Street 1:15 VANN AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-1444
Practice Address - Country:US
Practice Address - Phone:812-402-8333
Practice Address - Fax:812-402-8331
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004187A1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100240880Medicaid
IN000000634413OtherANTHEM
IN100240880Medicaid
IN100240880Medicaid
IN941190Medicare Oscar/Certification